Double balloon enteroscopy (DBE) coverage criteria
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Defines medical necessity, prior authorization, and documentation requirements for double balloon enteroscopy for Connecticut Medicaid (HUSKY) providers, affecting CMAP-enrolled providers and beneficiaries under HUSKY programs.
No material clinical or coverage changes in this revision.
Coverage Criteria for Double Balloon Enteroscopy (DBE)
Indications considered medically necessary
DBE may be considered medically necessary for any of the following indications:
Each listed indication alone may justify medical necessity per the guideline and individual clinical assessment.
No specific limitations are listed for double balloon enteroscopy in this policy. Limitations: N/A.
Coding and Billing
Provider Actions, Prior Authorization, and Documentation
PA required for retrograde (rectal) DBE
Prior authorization is required for double balloon enteroscopy when performed via a retrograde (rectal) approach; use CPT code 44799 for authorization.
Medical necessity–driven review
Coverage decisions follow the DSS definition of Medical Necessity and are determined by individual clinical assessment; the guideline indications are provided to support medical necessity determinations but do not replace the definition of Medical Necessity.
Required submission materials
Submit a fully completed authorization request via the web portal and include supporting medical record documentation that demonstrates the medical necessity of the requested DBE.
- Fully completed authorization request via web portal
- Documentation from the medical record supporting medical necessity
Risk of denial or delay for incomplete requests
Incomplete authorization requests or missing medical record documentation supporting medical necessity may result in denial or delay of coverage review.
Background
Double balloon enteroscopy (DBE) is an advanced endoscopic procedure that uses a long flexible enteroscope and an overtube equipped with two balloons—one on the scope tip and one on the overtube—to systematically pleat and advance the device through the small intestine. It can be performed via an anterograde (oral) or retrograde (rectal) approach to provide visualization of the small bowel and enable diagnostic biopsy and therapeutic interventions such as polypectomy, dilation of strictures, stent placement, and retrieval of retained objects (for example, retained video capsules).
Definitions
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